Nursing and midwifery professions are female in the majority, with only 11% of Nursing and Midwifery Council (NMC) registrants identifying as male (NMC, 2024). However, this is not mirrored across higher education (HE) generally, where men are proportionally better represented. The UK Council of Deans of Health's (CODH) analysis of the academic workforce for nursing, midwifery and allied health disciplines notes that 72.3% of staff identify as female (CODH, 2020). This is a better reflection of the gender split within clinical nursing and midwifery practice, although it does not fully represent the gender seniority inequalities therein.
The NHS is a female-dominated organisation, yet men consistently dominate senior board-level positions (NHS Confederation, 2019). Similarly, although there are more females among the nursing and midwifery HE workforce in general, men are disproportionately represented in senior and specialist academic and/or research roles (Evans, 2004; Cleary et al, 2019). They are also better represented in nursing and midwifery academia generally in comparison with caring for patients on the clinical front lines – 27.7% of academics in healthcare subjects are male compared with only 11% of those in clinical nursing and midwifery roles (CODH, 2020).
This gender divide of labour and seniority is an established barrier to career advancement for women both in the health service and in HE (Zacher et al, 2019). Although it may not be unusual, it is nonetheless striking in the context of female-dominated professions. If HE aims to seek social justice (UNESCO, 2022), in addition to improving health outcomes, women's voices must be heard at senior levels both within nursing and midwifery HE and in leading research excellence. There is therefore a need to better understand the female workforce's experiences in nursing and midwifery HE in order to comprehend how scholarly activity, progression, research and leadership can be encouraged, supported and developed for the female HE workforce.
Initial scoping reveals abundant literature relating to the experiences and challenges of female academics more broadly, where there is a dominant dialogue surrounding family caring responsibilities as an inhibitor to progression in research and leadership (Raddon, 2002; Baker, 2010; Rosa, 2022), alongside discussion of high workloads for female academics in the ‘ivory basement’ where they are allocated disproportionately high workloads for minimal recognition (Fitzgerald et al, 2012; Aiston and Jung, 2015). There are also a number of recent first-person narrative accounts and studies of early career nurse academics discussing their transition into academia (Blake, 2023; Scammell et al, 2023; Alegado, 2024; Axiak and Axiak, 2024; Barken and Robstad, 2024), although these again are not focused on the female experience specifically. Overall, there appears to be relatively little literature relating to the experiences of female nursing and/or midwifery academics in post.
The research question the author posed was therefore deliberately broad, being reflective of the dearth of specific literature identified in scoping. It sought to explore the experiences of the majority female workforce in nursing and midwifery HE to better define and understand any challenges and barriers to progression.
The research question was: ‘What are the experiences of the female nursing and midwifery higher education workforce?’
Method
Search strategy
The integrative review aimed to consider the literature more broadly to assimilate information from diverse data sources in order to develop new knowledge about a topic (da Silva et al, 2020). In this way, integrative reviews are better suited to the development of theory around an emerging topic rather than in testing, comparing or confirming established concepts, definitions or practices (Whittemore and Knafl, 2005). This approach fits with the broad question posed, which does not start from a position of established theory on the experiences of female academics within nursing and midwifery HE, as these do not appear to have been widely confirmed.
The Population, phenomenon of Interest, Context (PICo) model (Hosseini et al, 2024) was used to develop the research question and related synonyms (see Table 1). This was selected because it is targeted at developing broader qualitative questions and thus was better suited to the integrative approach. Three search strings were developed using the defined synonyms in combination with Boolean operators and truncation, and these were used to identify appropriate literature. The synonyms used were necessarily broad in order to retrieve any relevant literature that pertained to the topic because scoping had indicated there was an overall lack of focus on this specific topic.
| Population | Female higher education workforce | Women, woman, female | (wom* OR female) AND (“higher education” OR university OR HE OR academi* OR facult*) |
|---|---|---|---|
| Higher education, academia, faculty, university, HE | |||
| Interest | Experiences | Experiences, perceptions, views, narratives, accounts, observations | experience OR perception OR view OR narrative OR account OR observation |
| Context | Nursing and midwifery | Nursing, nurse, midwifery, midwife, midwives | (nurs* OR midwi*) |
Nine databases were searched in total, in view of the limited literature initially retrieved in scoping, and these were selected from all available and accessible health and education resources in view of the education-focused topic (CINAHL, Applied Social Sciences Index and Abstracts (ASSIA), British Education Index, Education Abstracts, Education Database (ProQuest), Education Resource Information Center (ERIC), Taylor & Francis, Social Science Database (ProQuest) and Wiley-Blackwell). The majority (n=6) of articles were retrieved from CINAHL. A reflexive approach to searching was adopted; it was noted that the three search strings initially returned extensive hits that were not directly relevant to the question and/or excluded articles that would be relevant by restricting the search to the synonyms defined against the ‘interest string’. As such, abstracts were manually screened from search results returned against the population and context strings alone to ensure all meaningful results were captured.
Inclusion and exclusion criteria were loose in view of the limited number of articles found; any article in English, published within the past 20 years and pertaining to the female nursing and midwifery HE workforce was included. This is in line with the broad integrative approach, which aims to include as much literature as possible for development of new knowledge against a small base where detailed inclusion and exclusion criteria are more likely to narrow results and/or introduce bias into search results, which would be limiting for literature on emerging topics (Dhollande et al, 2021).
Although initial hits appeared substantive, the majority were excluded in initial screening because they did not address the intended population. Of the 37 full-text articles finally assessed for eligibility, 30 were then further excluded (see Figure 1), leaving 7 studies for analysis.
Quality appraisal
All seven studies (see Table 2) were critiqued using the Hawker et al (2002) checklist, designed to enable systematic critical assessment and scoring of disparate data forms. The seven articles retrieved comprised one quantitative scoping study, two mixed-methods studies and four qualitative studies. The mixed-methods studies used surveys and questionnaires to capture both qualitative and quantitative data, two of the qualitative studies employed individual interviews, whereas two adopted an ethnographic approach. The scoping study retrieved publicly available information on university websites. Studies undertaken were global in nature, representing populations in Turkey (n=2), Australia (n=3) and the USA (n=2). Although the question and search terms related to both nursing and midwifery, only articles relating to nursing disciplines were found. Two of the articles by Glass (2003a; 2003b) were published concurrently in the same journal issue in two parts (the first part detailing methodology and methods, the second part documenting analysis and results). These were therefore critiqued as one article.
| Author(s) | Country | Date |
|---|---|---|
| Alaçam and Altuntaş | Turkey | 2017 |
| Glass | Australia | 2003a/2003b |
| Iheduru-Anderson et al) | USA | 2022 |
| Iheduru-Anderson and Shingles | USA | 2023 |
| Livesay et al | Australia | 2022 |
| Özberk and Yağcan | Turkey | 2023 |
Results
Thematic analysis was performed using a structured approach as described in Miles and Huberman (1994) and four themes were identified:
Multiple roles
Five of the six included articles discussed facets of the multiple roles that female nursing academics embody. In two Turkish studies (Alaçam and Altuntaş, 2017; Özberk and Yağcan, 2023) marriage was seen to be a negative career influence, particularly for those academics with less than 10 years' experience; either acting as a blocker to career advancement or adversely affecting the resilience of nursing academics during the COVID-19 pandemic. Although these resonate with the UK literature on the impeding impact of marriage on female careers (Howe-Walsh and Turnbull, 2016), it is important to note the influence of the geographical context here. Turkey has more traditional and rigid family roles and structures, with women less freely able to prioritise career over family (Alaçam and Altuntaş, 2017), so transferability of these findings to other cultures is more problematic.
It is also not clear how marriage is defined in these studies (a presumption here, again in the context of Turkish family culture, is that marriage equates to heterosexual marriage between a man and woman). This is again an important distinction to make in the context of transferability. Wider literature tends to illustrate that same-sex lesbian marriages may be a source of freedom and thus support for career progress (Allen and Goldberg, 2020). It is then perhaps not the concept of marriage that negatively impacts female academic careers but the traditional or stereotypical family gender roles that marriage can often reinforce.
Livesay et al (2022) also discussed the ‘role juggling’ activity of female nurse academics in the context of contractual employment. The study analysed the representation of females in leadership positions within nursing faculties in Australia. Unsurprisingly, whereas women dominated all roles within the 37 nursing faculties sampled (including leadership roles), men were disproportionately represented in senior roles in comparison with their representation in the wider nursing workforce. Additionally, two-thirds of the female nursing workforce sampled appeared to be casual workers. Again, this could be seen to be reflected in both the UK and global HE context; women academics are generally more often employed in casual work than men (Crimmins, 2017) and this flexibility may be beneficial for juggling family responsibilities. This can therefore be seen as a further complication to career advancement; casual workers then having much more limited access to support, mentoring, progression and promotion than those on permanent contracts.
Two further articles looking at the experiences of Black nurse academics noted further roles that are additionally expected of ‘racially minoritised’ female nursing academics: inclusion work and mentoring (Iheduru-Anderson et al, 2022; Iheduru-Anderson and Shingles, 2023). The work of anti-racism and inclusion was reported in qualitative narrative interviews by Black nurse academics as being expected of them by virtue of their race (Iheduru-Anderson et al, 2022). Some felt that, as they were in the minority in many settings dominated by white faculty members, they were called upon to speak for or provide insight into the views or lives of other ‘racially minoritised’ groups. Others were expected to lead on diversity or inclusion committees or work. This echoes the UK environment where Black women are similarly in the minority in nursing HE leadership roles (CODH, 2020). Additionally, with inclusion, anti-racism and increasing efforts to ‘decolonise’ or ‘liberate’ nursing curricula firmly on the HE agenda, this may pose an unacceptable added burden on many Black academics to ‘fix’ the racism inherent in the system.
The culture and content of health academia
The majority (n=5) of the articles reviewed discussed the particular culture (and sometimes) politics that are unique to the health academic environment (Glass, 2003b; Alaçam and Altuntaş, 2017; Livesay et al, 2022; Özberk and Yağcan, 2023). All reported a competitive culture that emphasises the importance of doctoral study, publication and an overall culture where more junior staff experience pressure to advance. This could of course potentially be said about any HE workplace; however, what was noted in Alaçam and Altuntaş's study (2017) is the increased workload of HE roles within health that could be seen to complicate success against an already long list of expected achievements. This is an established phenomenon in nursing and midwifery HE programmes where, in comparison with more ‘traditional’ subjects, academics generally contend with more teaching across longer programmes. Those regulated by the NMC must include a minimum of 2300 hours of theory, generally necessitating a much longer academic year (NMC, 2023a). They must also fulfil ‘extra’ roles as ‘academic assessors’ of student practice documentation or ‘link lecturers’, tasked with supporting students and practice assessors in clinical practice alongside regular redesign and revalidation of programmes against changing regulatory standards. This is in addition to the requirement to maintain professional registration on the NMC register (NMC, 2023b) and the attendant experiences, continuing professional development and clinical hours that must be achieved to support three-yearly revalidation (NMC, 2021).
Livesay et al (2022) and Glass (2003b) discussed the competitive nature of nursing academia from differing perspectives. Livesay et al (2022) identified a lack of nursing academics with doctorates and suggested that this is because nursing is not seen as scientific enough to warrant doctoral study. However, Glass (2003b) goes further, viewing the overt competition and comparison voiced between academics regarding doctoral qualifications as horizontal emotional violence that works to undermine both the physical and emotional wellbeing of the workforce. Both perspectives operate from a baseline where it is common for nursing or midwifery clinicians to enter academia without any postgraduate study, as the recent Royal College of Midwives (RCM) midwifery HE workforce report asserts (RCM, 2023). Additionally, many health academics are on teaching-only contracts (in Wales this is over 50% of the workforce (CODH, 2020)) – thus, in addition to lack of time, there is no institutional incentive (or support) to compete in fields of research or scholarly activity.
Benevolent sexism
Three articles reported on the nuances of sexism within the female HE nursing academy. The obvious sexism reported within the workforce remains so that, despite females dominating both clinical and HE roles in nursing, men are disproportionately represented in senior leadership within nursing HE. This was found in Livesay et al's (2022) scoping study of Australian nursing school information (where 18.5% of leadership positions within nursing programmes were held by men in comparison to only 13.7% of the wider academic staff and 8% of the clinical nursing workforce reported at the time of study). This is similarly mirrored across UK statistics, as previously discussed.
Livesay (2022) attempted to explain these statistics by postulating that leadership traits (such as assertiveness and decisiveness) are more often linked to men, whereas caring and nurturing are characteristics ascribed more frequently to women and, in particular, to women within caring disciplines such as nursing. Ideduru-Anderson et al (2022) similarly reported the expectation that Black female nursing academic leaders operate with a certain level of ‘niceness’, extending to having to be polite even when dealing with overt racism.
Glass (2003b) equally describes the necessity for women to be agreeable, not to question too much and having to look attractive or dress the right way in order to progress, a phenomenon that is still topical 20 years later and recently evident in the widespread media coverage of the UK's female deputy prime minister's work attire (Williams, 2024).
These facets of sexism could be said to reflect a ‘benevolent sexism’ – that is, patronising views posed as harmless, even positive, commentary on complementary gender differences (for example, women as nice, nurturing, caretakers) that only serve to reinforce the subordination of women and uphold traditional gender roles (Barreto and Doyle, 2022). This only compounds the issue of nursing being viewed as less than or not ‘scientific’ and the difficulties women nursing academics experience in obtaining doctoral qualifications; research indicates women experiencing such sexism may even experience decreased cognitive performance as a result (Castner, 2019).
Mentoring and peer support
A more encouraging theme elicited by half of the articles (n=3) related to mentoring and peer support, which was seen as a positive source of support for female nursing academics, whether through more formal means or through informal peer communities. Glass (2003b) discussed peer groups as being used to defuse tension, provide an environment for debriefing and offer comfort during times of conflict with more senior academics.
Alaçam and Altuntaş (2017) noted that mentoring was important for career progression for nursing academics in Turkey but that there was a general lack of nursing academics able or willing to act as role models or mentors, and this could be seen as an obstacle to advancement. This lack of mentors or role models is seen as particularly detrimental for minority groups; Black women experienced differences in accessibility and in the number of mentors and resources available compared with white counterparts (Iheduru-Anderson and Shingles, 2023). This is due to the overall lack of Black representation in nursing HE. Colour-blindness in mentoring was, however, noted as being problematic; Black nurses sought out mentoring from other nurses of colour and this was viewed as important. Finding appropriate Black mentors therefore necessitated accessing mentors outside of nursing disciplines or even in other institutions.
The timing of mentoring was also noted as being key. Early career mentoring was seen as crucial for progression (Iheduru-Anderson and Shingles, 2023). This was echoed by Livesay et al (2022), who outlined the importance of mentoring academic staff from their first entry into HE establishments in preparation for later promotion and leadership roles. Again, this career-crucial mentoring may not be as accessible in any formal sense (if at all) for staff employed flexibly on a casual basis as the majority workforce was seen to be in the Australian population described here.
Limitations
Overall, the studies retrieved in response to this broad question illustrate that the literature on this topic is still emerging and would ultimately benefit from a wider scoping or comprehensive integrative review that considers not only empirical and primary research but also wider theoretical knowledge in order to provide more coherent conclusions. There are clear issues in the transferability of much of the conclusions drawn here across geographic, cultural and social contexts (although, equally, some of the concepts discussed herein are global in nature, such as institutional racism, benevolent sexism and the traditional gender roles of women). It should also be noted that two of the six articles included were published by the same lead author and had a race-specific focus that may have impacted the completeness of the review, although these articles also identified and substantiated themes in the other articles reviewed. Confidence in general can be built in themes identified and conclusions drawn, in that they are corroborated by supporting theoretical literature (Castner, 2019; Cleary et al, 2019). Further limitations of the review, including gaps, tensions and recommendations for future research and review, are listed in Table 3.
| Limitation | Detail |
|---|---|
| Female focus of review | The search for a female nurse academic population excluded articles that considered gender inequalities from the context of male dominance (or male absence), which may have excluded some relevant literature |
| No midwifery papers | Conclusions could not be drawn about the midwifery higher education workforce as no empirical data could be found on this – this evidences a gap in the literature and a potential avenue for further research |
| Transferability | Although transferability is not necessarily sought (either in qualitative research or in integrative reviews) there are restrictions on the transferability of conclusions drawn between geographical regions and cultures |
| Gender focus within search | Removing gender from the search would have widened the results returned and allowed for a more focused question (for example, allowing focus on barriers to progression or leadership). This should be considered for future reviews: although there is interest in the specific female workforce as the workforce is itself inherently gendered, any conclusions drawn would nonetheless be meaningful for women |
Conclusion
This literature review aimed to explore the experiences of female academics within nursing and midwifery-specific higher education disciplines. The studies suggest that there are particular challenges associated with the majority female workforce within nursing HE that may differ from the wider HE context. These relate to the juggling of roles on top of academic expectations among a workforce that is renowned for being casual (particularly for women) working in disciplines where there is generally more to do to meet regulatory demands in addition to the usual ‘extra’ demands of publication and research expected of academics.
All this is against the backdrop of an innately sexist and gendered culture where nursing is not deemed scientific or academic enough (so pressures to achieve doctoral qualifications or publish research are higher), yet the caring work of the discipline appears typically dismissed as ‘women's work’ with men disproportionately represented in leadership roles. All of these issues are felt more keenly by minoritised Black academics who have additional pressures to contend with, including the burden of leading anti-racist work and mentoring of similarly minoritised junior staff within an innately racist system.
The implications for practice arising from the literature reviewed here appear to be rooted in the provision of mentoring and peer support for the female nursing academic and the framework developed by Iheduru-Anderson and Shingles (2023) provides an interesting perspective in the way that the development of the workforce is positioned as starting with the nursing students themselves and the education they receive. The theory here is that the students constitute the future nursing and nursing academic workforce and any aspirations to pursue academic or leadership roles can only be realised if female students have representation from diverse female educators and role models from the beginning of their training. It also gives a reason to carefully assess the representation of diverse female voices within nursing curricula if we are to seek to transform the patriarchal status quo that supports the disproportionate representation of men in nursing academia. Institutions would also do well to review the employment conditions of female nursing academics, perhaps to make a concerted move away from the career-stunting effect of casual work, although this will only be meaningful when permanent career expectations allow space for women to balance work alongside personal and family roles.